Failure to Address Increasing AIMS Scores: A resident receiving mirtazapine had rising AIMS scores from 0 to minimal and then mild abnormal involuntary movements. The facility documented no referrals were needed and continued the current plan of care, but there was no evidence the provider was notified or that the increasing scores were otherwise addressed; the DON/administrator stated the nurse did not know any action was needed.
A resident with intact cognition and limited assistance needs had a PRN diazepam order for anxiety with no stop date. The pharmacist flagged the order because it lacked a stop date and recommended discontinuation or documentation of the indication, intended duration, and rationale for continued use, but the provider response did not clarify this and follow-up for clarification did not occur.
The facility failed to ensure a psychotropic medication had an adequate indication for use for one resident and failed to have side effect monitoring in place for two residents. One resident received Seroquel for insomnia, but a consultant pharmacist noted there was no allowable diagnosis to support continued use and the chart did not show a new diagnosis attached to the order. Another resident with Alzheimer’s disease, dementia with anxiety and psychosis, and depression received Risperidone twice daily, but the EHR had no side effect monitoring for psychotropic medications; the DON confirmed monitoring was missing for two residents.
Failure to Complete GDR and Psychotropic Monitoring: A resident with anxiety, depression, and insomnia received duloxetine, trazodone, and buspirone, but the facility did not complete the required GDR for duloxetine in the required timeframe. The record also showed no documented monitoring of behaviors, side effects, or non-pharmacological interventions for duloxetine and trazodone, and the DON confirmed that psychotropic monitoring was only documented for buspirone.
Psychotropic Medication Lacked Approved Indication: A resident with dementia, psychotic disturbance of mood, anxiety, and depression received Seroquel 25 mg daily for mild dementia with agitation and Quetiapine 25 mg at bedtime for depression. The MAR showed both medications were administered daily, and the DON confirmed the listed indications were not manufacturer-recommended uses under the facility policy.
Failure to document non-pharmacological interventions before PRN psychotropic use. A resident with cerebral infarction, generalized weakness, and severely impaired cognitive skills had PRN lorazepam/Ativan orders for anxiety or restlessness, with specific non-pharm interventions listed in the order. On three administrations, the EMHR lacked documentation in PCC or POC of the resident’s behaviors, mood, symptoms, and responses to interventions before the medication was given, and the DON confirmed the documentation was missing.
Failure to Monitor Antipsychotic Medication Effects: The facility failed to monitor a resident for adverse effects related to antipsychotic use. A cognitively intact resident was receiving Rexulti for dementia-related diagnoses, but the MAR had no monitoring orders and the CCP had no plan for antipsychotic monitoring. The DON confirmed the required monitoring was not completed as required by facility policy.
The facility failed to identify and monitor resident-specific target behaviors for two residents receiving psychotropic meds, failed to monitor for EPS/tardive dyskinesia with antipsychotic use, and used an inappropriate diagnosis for risperidone in one resident. One resident had intact cognition with depression, anxiety, hemiplegia, and seizure disorder, while the other had moderate cognitive impairment with dementia and depression; records and the DON confirmed that the CCP, orders, MAR, and EMR did not include resident-specific behavior monitoring or EPS assessments.
Missing End Date for PRN Psychotropic Medication: A resident with COPD, DM2, schizophrenia, bipolar disorder, depression, and anxiety had a PRN clonazepam order for anxiety with no end date. The pharmacist noted PRN psychotropic meds should have a stop date unless the provider documents a clinical rationale and new duration, and the ADON confirmed the MAR/record lacked an end date.
Psychotropic medication monitoring deficiencies were identified for multiple residents. One resident with bipolar disorder, MDD with psychotic symptoms, and GAD received Seroquel and sertraline, but the EMR, MAR, and TAR did not show specific target behaviors or side effect monitoring despite behavioral concerns being listed in the care plan. Another resident with schizoaffective disorder, bipolar type, received multiple psychotropic medications, but no target behaviors were documented, and the DON confirmed this. The report also noted missing AIMS testing for one resident and lack of sleep pattern monitoring for hypnotic use in three residents.
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